Introduction

The Oliver Zangwill Centre (OZC) for Neuropsychological Rehabilitation opened in 1996 and was modelled on the American holistic programmes developed by Yehuda Ben-Yishay and George Prigatano. It was named after Oliver Louis Zangwill, Professor of Psychology at Cambridge University between 1954 and 1984. He was also a pioneer of brain injury rehabilitation in Great Britain during the Second World War when he worked in Edinburgh with brain injured soldiers. The Centre follows many of the principles laid down by Ben-Yishay (1978), Prigatano et al. (1986) and Christensen and Teasdale (1995), and is also significantly influenced by the critical ‘scientist practitioner’ model of clinical psychology adopted in the United Kingdom.

A holistic approach to brain injury rehabilitation ‘… consists of well-integrated interventions that exceed in scope, as well as in kind, those highly specific and circumscribed interventions which are usually subsumed under the term “cognitive remediation”’ (Ben-Yishay and Prigatano, 1990; p. 40). The holistic approach recognizes that it does not make sense to separate the cognitive, emotional and social consequences of brain injury as how we feel and think affects how we behave. Ben-Yishay's (1978) model follows a hierarchy of stages through which the patient or client should work in rehabilitation. These stages are engagement, awareness, mastery, control, acceptance and identity. Individual and group sessions are provided to enable patients to work through these stages.

The origins of the OZC go back to 1993 when one of us (BAW) spent several weeks at Prigatano's unit in Phoenix Arizona.

In order to illustrate our developing approach to interdisciplinary rehabilitation, we describe our work with Yusuf. He was one of the first clients with whom teamwork was organized across a range of impairments, activities and contexts, which in turn fed into increased social participation in one key goal area. The work also provides a good example of formulation-based rehabilitation, which provides a means of integrating assessment results, and developing a ‘shared understanding’ across the team and with the client. Since our work with this client we have sought to develop these principles further to become formalized aspects of the rehabilitation programme, as described in the ‘core components’ (Chapter 4), and in more detail in our work with Judith (Chapter 17). The case also highlights specific successful interdisciplinary interventions for pain and fatigue delivered as part of the integrated rehabilitation programme.

History of injury

Yusuf was involved in a car accident in May 1998. He was in coma for a week, and post-traumatic amnesia was reported to last for about a month, indicating a very severe head injury. Computerized tomography (CT) scans at the time of injury identified a left fronto-temporo-parietal subdural haematoma, which was causing some mass effect on the left cerebral hemisphere and left lateral ventricle.

Social history

Yusuf was a 35-year-old man (32 at time of injury) who lived with his wife and three young children.

Introduction

The Mood Management Group is an integral part of the programme at the Oliver Zangwill Centre for Neuropsychological Rehabilitation. Although clients attend the Psychological Support Group and individual mood sessions, it is clear that clients experience common emotional sequelae (Williams and Evans, 2003) that benefit from a group approach.

Whilst the Psychological Support Group (Chapter 9) provides a protected space and time for clients to support one another, to reflect and to apply cognitive and communication skills in a group setting, the Mood Management Group provides a ‘normalizing’, psychoeducational and strategy focused approach. The group process of sharing experiences and reflecting on how learning in rehabilitation may apply to oneself or others is still important, but is less central than in the Psychological Support Group. Practically, it enables clinicians to share a greater amount of information with clients than possible in individual sessions. As a result of this group, it is hoped that clients have a greater understanding of their own and others' emotional goals, challenges, strengths and strategies, and can share perspectives and develop self-awareness. This aims to empower individual clients so the group members can support each other more effectively.

Aims of the group

In the Centre policies and procedures, we describe the aim of the group as follows:

Introduction

The emotional sequelae of acquired brain injury (ABI) are now well documented and increased attention in the literature is being paid to intervention. In addition to this, research has identified the profound impact of ABI on sense of identity (Tyerman and Humphrey, 1984; Nochi, 1998; Cantor et al., 2005; Dewar and Gracey, 2007). Ylvisaker and Feeney (2000) present a rehabilitative approach that explicitly involves developing ‘identity maps’ with their clients, and McGrath and King (2004) describe how behavioural experiments in cognitive behaviour therapy (CBT) can address beliefs and assumptions about self and abilities following ABI. As we described in earlier chapters (e.g. Chapter 4), such work is a key feature of the Oliver Zangwill Centre (OZC) for Neuropsychological Rehabilitation.

At the OZC we have been developing the application of CBT beyond treatment of Axis 1 emotional disorders following ABI (see Williams and Evans, 2003) to explore applications for facilitating acceptance and adjustment across the holistic rehabilitation process. This case illustrates two important aspects of this innovative modification of CBT: the use of behavioural experiments in rehabilitation (McGrath and King, 2004), and the constructive development of what we call a ‘positive formulation’ to support identity change and adjustment (Mooney and Padesky, 2000; Ylvisaker and Feeney, 2000). The chapter shows how these methods enabled Judith to change the meanings associated with attempts to engage in meaningful activities through the programme, with some enduring behaviour change maintained for a year post-programme.

Introduction

Over the past 25 years or so there have been a number of major changes in neuropsychological rehabilitation. First it is now much more of a partnership than it was in the 1970s and 80s. Then doctors, therapists and psychologists decided what patients should and could hope to achieve from rehabilitation programmes. Now we discuss with families and patients what they hope to get from rehabilitation and we try to accommodate to this at least in part. Second, rehabilitation has moved well beyond the drills and exercise approach. We no longer find it acceptable to sit people in front of a computer or workbook in the belief that such exercises will result in improved cognitive and, more importantly, social functioning. Third, rehabilitation staff now follow a goal setting approach when planning rehabilitation programmes. Clients, families and staff negotiate appropriate goals and determine how these are to be achieved. Fourth, there is increasing recognition that the cognitive, emotional, social and behavioural consequences of brain injury are interlinked and all should be addressed in the rehabilitation process. Fifth, technology is playing a larger part than ever before in helping people with cognitive deficits compensate for their problems. Sixth, it is now more widely accepted that no one model, theory or framework is sufficient to deal with the many and complex difficulties faced by people with neuropsychological impairments following an injury or insult to the brain.

Introduction

Previous chapters have described the principles of neuro psychological rehabilitation and outlined the Oliver Zangwill Centre (OZC) for Neuropsychological Rehabilitation programme providing descriptions of groups developed to address specific types of difficulties experienced by many individuals following acquired brain injury. In addition, within a holistic neuropsychological rehabilitation setting, other groups may be run according to shared needs of the individuals undertaking the programme at any one time. This chapter aims to identify some of the types of groups that have been utilized and discusses the format, content and ways in which such group work can be integrated within individual rehabilitation programmes. Group attendance is discussed and agreed as plans of action towards individualized client goals, which help to co-ordinate the activities of the clinical team.

Within society, people are members of one group or another, within the home, at work or in recreational and social interests. Groups provide us with a shared identity and roles, in addition to peer support, and we know that many people experience a loss of role and purpose and a sense of isolation after brain injury. Klinger (2005), summarizing the results of a qualitative study with traumatic brain injury participants, notes: ‘participants had to learn a new way of “being” in order to move on to a new way of “doing”’ (p. 14). A similar finding is reported by Gracey et al. (2008). Group activity is thus of central importance to the programme especially the ‘therapeutic milieu’ core component.

Introduction

In Chapter 1 we presented a model of rehabilitation that highlights the range of theories that may be drawn upon to support the identification and development of interventions for the many consequences of brain injury or illness. The case presented here highlights in practice how cognitive neuropsychological intervention (as defined by Coltheart (2005)) can be integrated into neuropsychological rehabilitation, with a specific emphasis on communication and numeracy. The importance of learning method is also raised both in terms of learning specific skills or information as well as functional generalization.

We describe our work with Lorna as a further example of our interdisciplinary approach, in which team members worked in an integrated way with the client towards shared functional goals. Significantly, Lorna's level of communication was initially considered a potential barrier to her ability to benefit from the groups and participate fully in the therapeutic milieu process. Subsequently these concerns appeared largely unfounded.

Once again a formulation-based approach provided a means of integrating assessment results, developing a collaborative understanding regarding the client's needs and building a basis upon which to address these across the team. The case highlights specific and successful interventions for naming and numeracy difficulties, as well as development of compensatory strategies, together applied to increase participation in meaningful activities as part of the integrated rehabilitation programme.

History of injury

Lorna suffered a brain injury in May 1999 whilst living and working abroad.

Introduction

How should we plan and evaluate rehabilitation? We will argue here that the most appropriate way to plan, direct and measure the success of rehabilitation is through the process of goal setting. If neuropsychological rehabilitation is ultimately concerned with enabling people with brain injury to participate effectively in valued activities, then it follows that we should measure the outcome of an individual's rehabilitation programme in terms of whether or not the programme enables that individual to achieve his/her personal goals. If outcome is defined in terms of personal goals, then it makes sense that these goals should be the central focus when planning the specific components of a rehabilitation programme.

In relation to evaluation of outcome, if one is evaluating a specific treatment intervention that aims to improve a particular cognitive function, then it is useful to have an assessment of that cognitive function as an outcome measure. However, even when evaluating a specific treatment it is important to measure the extent to which the intervention improves the client's functioning in his/her everyday life. Some studies aiming to evaluate cognitive or neuropsychological rehabilitation programmes use standardized neuropsychological tests as their main, or only, outcome measure (see, for example, the studies reviewed by Carney et al., 1999). We would argue that use of such tests, on their own, either to plan or to evaluate rehabilitation programmes is wrong.

The therapeutic milieu in holistic rehabilitation

Holistic rehabilitation aims to create and operate within a therapeutic milieu, a supportive and therapeutic social context that is argued to support the process of change (Goldstein, 1942, 1959; Ben-Yishay, 1996, 2000). Ben-Yishay argues that this social context helps clients develop their sense of identity that they can then take back out into the world and other social contexts such as families, friends and work or college situations. At the Oliver Zangwill Centre (OZC) for Neuropsychological Rehabilitation, as with other holistic programmes, practices such as a daily community meeting, and an emphasis on group learning, contribute to the therapeutic milieu. In some programmes, the community meeting is used therapeutically as an opportunity for clients to feedback to one another regarding socially inappropriate behaviour, or successful use of coping strategies (e.g. Prigatano, 1999; Daniels-Zide and Ben-Yishay, 2000). At the OZC feedback between and to clients is supported in smaller group sessions such as the Communication Group and other functional groups, as described elsewhere in this volume. On occasion a more general discussion about expectations of one another's behaviour may occur during the community meeting. At the end of the week, the staff and intensive phase clients come together to review the points of learning from the groups and exercises completed over the week.